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66 yo black male to PCP c/o episodes of moderate chest pressure x 3 weeks increasing in frequency and duration. Chest discomfort is exacerbated with strenuous activity and eases with rest. PMHx smokes 1.5 packs of cigarettes per day x 40 years and has history of mild gastrosophageal reflux for 20 years for which he takes sodium bicarb in water when needed. Family history no significant medical history. The client denies any discomfort or pain at the present time. The nurse begins an assessment with vital signs, noting the client has a relaxed facial expression, a calm demeanor, and speaks in full sentences. The client is awake, alert, and oriented to person, place, time, and situation. He responds to questions appropriately. Cardiovascular assessment: no JVD, heart sounds with regular rate & rhythm, no murmurs. PMI WDL. No carotid bruits. No edema noted Bilateral to BUE or BLE, Cap refill is < 3 seconds. Skin is warm and dry to touch; oral mucosa and conjunctiva are pink. Respiratory assessment: full and equal lung expansion; BS CTA bilat. Abdominal assessment: abdomen is soft, slightly rounded, no visible swelling, pulsations, or vower masses; percussion is within defined limits; no abdominal thrills or bruits noted; BTs present and extrem normoactive x 4 quadrants. Genitourinary assessment: deferred. Skin assessment: other than previous information described, no additional significant findings. SCIENCE HEALTH SCIENCE NURSING NURSING 182

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